AR
TICLE
Brazilian Federal District Health council actions regarding
the Primary Health Care reform, 2016 to 2018: case study
Abstract The Social Participation in Health has been consolidated in the Unified Health System through the efforts of the Municipal, State, Na-tional Councils and Health Conferences. The division into municipalities isconstitutionally prohibited in the Federal District and, therefore, there is a District Health Council and the Re-gional Health Councils. The aim was to describe the profile of the Federal District Health Coun-cil, analyzing its actions in Primary Health Care from 2016 to 2018. This was a qualitative case study, with documentary collection using the Ira-muteq software. A statistical report of the Health Council Monitoring System and public minutes of the Federal District Health Council were col-lected, dispensing with approval by the Ethics Committee. The Federal District Health Council is in agreement to what was stated in Resolution 453/2012 of the National Health Council. We analyzed 43 minutes, generating two categories and five classes. It was concluded that the Feder-al District HeFeder-alth Council originated the reform of Primary Health Care during the study period, through the publication of a resolution that es-tablished guidelines for the reorganization of the primary care level.
Key words Health systems, Unified health sys-tem, Community participation, Primary health care, Qualitative research
Danylo Santos Silva Vilaça (https://orcid.org/0000-0002-3676-7372) 1 Danielle Soares Cavalcante (https://orcid.org/0000-0001-6263-5835) 2 Luciana Melo de Moura (https://orcid.org/0000-0002-4514-2171) 2
1 Programa de Pós-Graduação em Ciências e Tecnologias, Faculdade de Ceilândia, Universidade de Brasília. Centro Metropolitano conjunto A/ lote 01, Ceilândia. 72220-275 Ceilândia DF Brasil. danylovilaca.unb@ gmail.com 2 Secretaria de Estado de
Saúde do Distrito Federal. Brasília DF Brasil.
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Introduction
For a long time, Social Control has encompassed a principle of authoritarian and regressive inspi-ration, practiced by the Government in its rela-tionship with society, assuming repressive char-acteristics, keeping society inits subservience1,2. In the past, there was the opposite of the para-digm of citizenship observed today, despite the fact that society is being controlled by the gov-ernment’sactions.
Social Control, in a participatory manner and as a component of the Government’sinstitu-tionality, is a recent reality in the Brazilian his-torical process, with the 1980s being the theoret-ical landmark of its institutionalization, namely: constitutionally instituted and ruled by specific legislation and resolutions, of which attribution-sare situated in the deliberation, co-manage-ment, monitoring, formulation and inspection of health policies at Municipal, State / District and Federal levels3-5.
Once this history was rescued, we chose to use the term Social Participation in Health to re-fer to the democratic interventions existing in the Health Councils to replace the term social
con-trol in health. The Social Participation in Health
was institutionalized in the Unified Health Sys-tem (SUS) through Law N. 8142 of 1990 which establishes, among other issues, that the Health Councils are permanent deliberative bodies4, of which composition equally occurs between 50% of users, 25% of SUS workers and 25% of man-agers and service providers5. In addition to the Health Councils, there are Health Conferences that occur ascendingly(regional/municipal, state/ district and national stages) every four years. Health councils and conferences are consolidated as participatory democracy mechanisms, adopt-ed by relatadopt-ed areas and also differentones from the health area6. Both Councils and Health Con-ferences, adjusted to the principle of community participation, are public spaces for collective de-liberation on the guidelines that must guide the structuring and management of SUS7.
In this sense, what would be the role of the Health Council in the reform of the Federal Dis-tricthealth system? What would the health sys-tem be and why reform it? TheHealth Syssys-tem is understood as the set of political and economic relations responsible for the health care of a cer-tain population, which are operationalized in ac-tions, services and pacts, preconized by the con-ception of health prevailing in the society that implements it8.
The Federal District is a unique federation en-tity in the Brazilian reality that requires attention for its singularities, especially in the health sector. The health system reform is a challenge required by the improvement of the health and life condi-tions of the populacondi-tions and by the inconclusive processes of public health policy effectiveness of the Federal District. These processes, which areu-nfinished or undergoing constant implementa-tion, are related to Primary Health Care, as care controller and coordinator of the Health Care Network (HCN), the Psychosocial Care Network (PCN), as well as the processes of regulation, de-centralization and regionalization of health. Thus, the aim of this study was to draw the profile of the Federal District Health Council and analyze its performance in the creation, proposal of strategies and in the control of health policyperformancein Primary Health Care from 2016 to 2018.
Methods
This is a qualitative research, based on an intrin-sic case study, covering the actions of the Fed-eral District Health Council (CSDF) in relation to Primary Health Care (PHC). Intrinsic case studies are those in which the case constitutes the research object itself, being justified its use in unique or special cases9.
The assertion that the CSDF is a unique case in the Brazilian reality is justified by the distinct political-administrative organization of the Fed-eral District, when compared to the other Brazil-ian Federation Units, in spite of the observation of the nonexistence of multiple municipalities, but of 31 Administrative Regions.
According to estimates by the Brazilian Insti-tute of Geography and Statistics (IBGE,Instituto
Brasileiro de Geografia e Estatística), Brazil has 27
Federation Units, with 5,570 municipalities and a total population estimated at 207 million in-dividuals in 2017. The Federal District is one of these FederationUnits, having Brasília (RA I) as a municipality.
The last demographic census, carried out in 2010, pointed out that there is a population of more than 2.5 million individuals in the Federal District10. The estimated population for the year 2017 was over 3 million. The Human Develop-ment Index (HDI) of Brasília was 0.824 in 2010, the last year in which the measure ranging be-tween 0 and 1 was conceived10.
This rapid demographic and territorial char-acterization, together with the well-known
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torical underfinancing, presupposes the existence of a network of complex and at times insufficient health services, according to the capacity of avail-able human and financial resources. The health service network characteristics are related to the performance of the Health Councils, which be-come more active as the network demands in-crease11.
The case study proposed herein was carried out through a mixed methodof research using the convergent parallel study design12, referring to (i) the descriptive statistics for characteri-zation of the Federal District Health Council profile, based on the existing data in the Health Council Monitoring System (SIACS) and (ii) the document analysis, supported by the internal regulations and minutes of the Federal District Health Council, from 2016 to the fifth month of 2018. The collection period comprised the peri-od between the months of April and May 2018.
The SIACS details the organization, operation and compliance of legal standards related to So-cial Participation in Health in the SUS. The data for profile characterization, as well as the min-utes of the CSDF constitute public documents and are easily accessed, justifying the choice for their analysis. The inclusion criterion consists of updated data (2018) related to the institutional-ized spaces of social participation in health in the Federal District.The data exclusion criterion was the fact of having no relevance for characteriza-tion purposes, such as administrative data or in-formation on physical and electronic addresses.
The selected analysis period, from 2016 to 2018, was chosen because it is the year after the conclusion of the 9th Health Conference of the Federal District that took place in 2015, the last conference that established the guidelines that directed the health policy in the following years, especially regarding Primary Health Care and the processes of decentralization and regionaliza-tion in the region. The end of the study analysis corresponds to the most recent year available for analysis (2018).
Data analysis consisted of basic statistics (ab-solute numbers and percentages) for the CSDF profile and the creation of a matrix of selection and analysis of the minutes, by carrying out a search using the following keywords: “Primary Health Care”, “PHC”, “Basic Health Care”, “Fam-ily Health Strategy”, “FHS”, “Fam“Fam-ily Health Pro-gram”, “FHP” and “Conversion”.
The keywords found in the minutes were copied together with the context in which they were found. Based on the selection and analysis
matrix, we selected the minutes that had at least one keyword in their content. The minutes were gathered into a text corpus and with the help of a public-domain software, called Iramuteq, it was possible to perform the lexicographic analysis of the content of these documents.Initially the ba-sic lexicographic analysis was performed, which mainly covers the lemmatization and word fre-quency calculations, multivariate analyses us-ing the Descendus-ing Hierarchical Classification (DHC) and post-factorial correspondence anal-ysis13.
The inclusion criteria of the minutes referred to the minutes of the ordinary and extraordinary meetings of the CSDF, as well as the existence of the descriptors in each selected minute. The ex-clusion criteria comprised the lack of inex-clusion of key words in the minutes. As it used secondary and public domain data, itdid not require ap-proval by the Research Ethics Committee (REC). However, the Standard for Qualitative Research Reports14 was considered to add scientific reli-ability to the study.
Results
Description of the Federal District Health Council profile in 2018
The Federal District Health Council (CSDF) had an updated registry in the Health Council Monitoring System in 2018. Through the sta-tistical report, as well as the statement provided by the system, it was possible to situate the an-alyzed council in comparison to other Brazilian councils, as well as in the region of the country where it is located (Table 1). One can observethe concerns about the equality provided by the reg-ulations that institutionalize Social Participation in Health.
At the national level, there was a significant registering of Health Councils in SIACS, also established in the great majority by legal instru-ments. Similarly, a large portion of the Municipal Health Councils formally established in the Mid-west are monitored, which is not the case for the Federal District, specifically.There were six health councils registered in SIACS. Of all the registered councils, five correspond to the Municipal Health Councils and one to the State Health Council, with the latter being related to the CSDF and the other five to the Regional Councils (Table 2). It should be clarified that there are no multi-ple municipalities in the Federal District, so the
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Municipal Councils to which the SIACS refers to correspond to the Regional Councils of five Ad-ministrative Regions of the Federal District.
The CSDF is a permanent instance of SUS so-cial participation. It was instituted through De-cree n. 2,225 of March 28, 1973, with its Internal Regulations being formalized in Resolution n. 32, dated of November 22, 2011. According to the
characterization obtained through the SIACS, it is a council chaired by a representative of the us-er’s segment, female, with age ranging from 51 to 60 years. It performs the training of counselors, has its own headquarters, as well as an Executive Board and Executive Secretary with a College/ University degree.
The CSDF consists of 28 health councils, 14 of which correspond to the user’s segment, 7 to the worker’s segment and 7 to the segment of managers and service providers. It states that it is in agreement to what is established in Resolu-tion n. 333/2003 of the NaResolu-tional Health Council. According to internal regulations, minutes of the meetings and information on the CSDF website, the council has budgetary allocation, uses per-manent committees, performs and participates in training processes.
Ordinary meetings are held monthly, and when necessary, special meetings are held; the president may belong to any segment, as long as they are chosen through vote, meetings are open, and the public has the right to speak when previ-ously authorized by the full board.The meetings are published on the website of the Federal Dis-trict State Health Secretariat (SHS-DF).
Federal District Health Council Actions regarding the Primary Health Care Level Conversion
It was observed that 23 minutes (53.5%) were related to ordinary meetings and 20 (46.5%) to extraordinary meetings of the Federal District Health Council. The included minutes (n = 43) resulted in 81.1% of the total collected (Figure Table 1. Statements of Health Councils in Brazil, Midwest and the Federal District, Health Council Monitoring System, November 2017.
Statement Tool Resolution
#453/12 With SIACS Without
Total IBGE
Brazil Total IBGE N n % n % n
Lei 3351 4657 82,70 974 17,30 5631 Decreto 99 Portaria 35 Midwest Lei 274 411 81,39 94 18,61 505 Decreto 13 Portaria 5 DF Lei 0 6 16,67 30 83,33 36 Decreto 2 Portaria 3
Source: Health Council Monitoring System, DATASUS, 2017.
Table 2. Statistical Report of the Federal District Health Councils in the Health Council Monitoring System, November 2017. Type of Council n % State 1 16,67 Municipal 5 88,33 Creation tool Decree 2 33,33 Ordinance 4 66,67 Internal Committees Yes 3 50 No 3 50 Periodicity Monthly meeting 4 66,67 Biweeklymeetings 2 33,33 Total 6 100
Total health councilorsper segment n %
Users 84 50
Health care workers 42 25
Service providers 8 5
Managers 34 20
Total 168 100
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1). The mean health councilors’ participation in the studied period (2016 to 2018), by segment, resulted in 37.81% for the user’s segment, 29.4% forthe health workers’ segment, 26.2% forthe managers’ and service providers’ segment and 6.6% of justified absences.
The corpus of the minutes, analyzed by the IRAMUTEQ software, recognized 43 units of texts from the Descending Hierarchical Classifi-cation (DHC). We identified 2,957 text segments, retaining 86.74% of the total, which generated 2 categories of analysis, one containing 3 classes and the other containing 2 classes, with 5 class-es in total (Figure 2). The software divided the corpus into three subcorpus: the first comprising classes 2 and 3, the second comprising classes 1 and 4, and the third comprising classes 5 and to-gether with classes 1 and 4.
Detailing of the Descending Hierarchical Classification (DHC)
Class 1, termed “The social participation between legal, political adequacies and of man-agement models”, accounted for 21.6% of text segments. The main elements (words) related to this class were: politics, public, dialogue, man-agement, social control, politician, and worker, among others (Figure 2) The content of Class 1 dealt mainly with subjects related to manage-ment models, including the social participation in the legal and ideological scope in this process. The excerpts shown below outline this context:
Excerpt 1. [...] Said that the user’s
participa-tion is important, and it is up to the users to say whether the answer was to their satisfaction or not, reaffirmed the importance of the user in the deci-sions and deliberations, praising the social partic-ipation regarding the of health policy decisions in the DF.
Excerpt 2. [...] Said that the manifestation of
the council has been carried outthrough the public model and format and considered it important to have a discussion before other proposals regarding management models, Institutes, Oscips, etc. appear. He stressed that the council must manifest itself.
Excerpt 3. [...] Said he thinks it is unfair to
us-ers to withdraw the possibility of stringently ana-lyzing the issue and said that as a manager he has the obligation to analyze all management models and as along-time manager he recognizes in each model advantages and disadvantage, ass none is perfect.
Class 2 entitled “Rite of regulatoryconduc-tionof meetings: performance of the councilors in relation to the management instruments being discussed”, was responsible for 18.8% of the text excerpts. The main segments related to this class were: committee, president, meeting, opinion, plenary, RAG (Annual Management Report), CSDF (Federal District Health Council), high-light, referral, voting, counselor, among others (Figure 2).
The content of this class depicts the forma-tion of the several committees in order to qualify the debate, conveys the organization of the
Re-Figure 1. Flowchart of the selection process of the Federal District Health Council minutes, from 2016 to 2018. Source: Federal District Health Council Official Minutes, January 2016 toMay 2018.
N. of CSDF official minutes collected = 53 (Minutes n. 367 to 414) N. of Minutes that included keywords = 43 N. of Minutes included = 43 N. of Minutes excluded because they did not have a record of the keywords = 10 (Minutes n. 369, 373, 379, 382, 383, 391, 403, 404, 408, 414). Id ent ificat io n Sel ec ti on Inc lusio n
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gional and District Health Conferences, as well as the commitment to implement the propos-als coming from the conferences, regarding the management decentralization. It describes the activities of the councilors through ordinary and extraordinary plenary meetings of the council, committee meetings, meetings with the legisla-tive chamber, with the attorney general’s office and the Superintendences.
Excerpt 1. [...] proposed the implementation of
a committee whose fundamental base is the PHC technical chamber,consisting mainly of individuals from the SHS management to define the PHC stra-tegic plan for the DF.
Excerpt 2. [...] in a health seminar in which
only representatives of the workers’ segment were present and stressed the importance of the seminar ... reminded that it is necessary to verify the budget for the health conferences of 2017.
Excerpt 3. [...] president of the CSDF stressed
that the decree was not a unilateral act of the gov-ernor; he carried out what was approved at the 9th
conference, corroborating with all previous confer-ences that recommended the health management decentralization to regional.
Class 3, characterized as “Rite of regulatory-conduction ofmeetings: administration, proce-dural developments and completion of several is-Figure 2. Descending Hierarchical Classification of the contents of the CSDF minutes selected from January 2016 to May 2018, Brasília, DF, 2018.
Source: Corpus processed in the Iramuteq software, version 0.7 alpha 2
Class 5 Class 1 Class 4 Class 3 Class 2
22,1% 21,6 % 23,4 % 14,1 % 18,8 % past year inform million resource real bidding get contract equipment purchase center hmib expense hiring company medicine generate enter payment reagent value already week politics tell no public dialogue here management social control political worker semore speak thing legal emphasize need all society including participation hand Implementation nothing very care attention assistance team fhs network phc need service server unity question population observe must emergency aids answer hr defend user hsvp to manifest item coordination presidency boardroom csdf exhibitor presentation ro unanimity to approve re approval quorum inclusion theme executive Secretary effect start report deliberation qualified inversion guest president commission president meeting Opinion full rag csdf Spotlight refer voting counselor piantino text vote Helvetian order election Danielle explain obstruction clarify proposal independent pas referral read
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sues”, was responsible for 22.1% of text excerpts. The main elements related to this class were: coordination, chair, board of directors, CSDF, exhibitor, presentation, agenda, among others (Figure 2). The content of this class portrays the presentation of the topics / items discussed in the agenda in the Health Council Plenary, inclusion and / or inversion of items and approval of the agenda through the voting process, as well as an appropriate quorum for deliberation and ap-proval of the annual managementreport, annu-al heannu-alth plan and minutes. The excerpts below show a close definition:
Excerpt 1. [...] Read the agenda and proposed
the inclusion in the agenda of the approval of the calendar of the CSDF meetings for 2018, in addi-tion to the presentaaddi-tion of the minuteof resoluaddi-tion N. 491, suggesting that this should be the first item, followed by the appraisal and approval of the cal-endar of CSDF meetings for 2018, presentation of the annual RAG management report for 2016 and, lastly, the PHC service infrastructure in health.
Excerpt 2. [...] President of the CSDF started
the meeting explaining his motivation and then gave the floor to the presentation, discussion, and deliberation of the ... 2017 annual health plan.
Excerpt 3. [...] President of the CSDF started
the meeting presenting the minutes for approval, until the quorum for deliberation was established, quoted and clarified to theplenary the content of resolution 465 of the CSDF that deals with repre-sentativeness.
Class 4, called “Instruments and actions aimed at the structuring of Primary Health Care as a regulator of the service network and levels of health care”, accounted for 23.4% of the text segments, showingthe greatest percentage in the analysis. The main elements related to this class were: care, attention, assistance, equip (equip, equipment), FHS (Family Health Strategy, Net-work, PHC, (Primary Health Care), necessity, service, family, civil servant, unit, question, popu-lation, and observe, among others (Figure 1). The content of this Class depicts how often the health care levels of SUS were discussed during the stud-ied period, mainly related to PHC and the future perspectives of Secondary Attention structuring.
Excerpt 1. [...] Thus, as a personal highlight,
PHC acts as a regulator through the identification of users’ needs, while coordination is management, and when we reach the other levels of health care, the main levels must be clearly defined in the PHC reform itself.
Excerpt 2. [...] Has drawn attention to the logic
of the PHC, as the question of where the workers
are assigned to in the network has already been brought to the CSDF, that it is necessary for the CSDF to bring to bear this responsibility of discuss-ing the allocation of HR in the network.
Excerpt 3. [...] Thanked the SHS for having
considered the work of the permanent committee and emphasized that changing workers’assign-ments is difficult, but there are plans to achieve success and commented that is the correct path, as one cannot perform PHS except through FHS.
Class 5, identified by “Temporalities for bid-ding, hiring, purchasing, performing and pay-ment of supplies and personnel”, accounted for 22.1% of the text segments. The main elements that are related to this class were: past, year, in-form, million, resource, real, bidding, obtaining, contract, equipment, purchase, center, among others (Figure 2). The content of this class dis-closes the recurrent discussions of the CSDF re-garding the inspection and hiring of services and personnel, as well as of bidding processes and purchase of supplies. The excerpts expressing this context are shown below:
Excerpt 1. [...] Concluded the presentation by
explaining the need to extend for two more years the processes of acquisition of materials and sup-plies through a CSDF deliberation.
Excerpt 2. [...] Mentioned as a second step
that when it is possible to organize adequately the SUAG health fund,aiming to have good hiring and cost regulation routines, the regions will be trained so they can perform their own actions and then it will be the responsibility of the regional superinten-dents to do that.
Excerpt 3. [...] Said there is a lack of human
resources in the SHS as a whole, in both heart sur-gery, surgical center, but there is also a lack of hir-ing, procurement and maintenance processes.
Discussion
Evidence on the deliberative behavior of the Fed-eral District Health Council (CSDF) worked as a trigger to conduct a discussion based on the un-derstandings related to deliberative democracy. Expressive international scientific contribution on deliberative practice started to associate it with the effectiveness of deliberation15,16.
The possible consequences of political de-cisions affect those who make them. This is a
hypothesis, presented by Habermas17, widely
accepted in the theory that establishes delibera-tive democracy. In association with it, we found a Health Council in constant activity,
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ed by a representative of the users’ segment. In what aspects could the CSDF profile influ-ence the products decided by this instance?The CSDF –when compared to the national scenario with more than 4,600 legally established Health Councils,and to the Midwest region,to which it belongs, with more than 400 legally instituted Health Councils –have the challenge of repre-senting, together with the Regional Health Coun-cils, the demands of more than two million users, as well as the complexity of the health system in the region with a predominance of health facili-ties under the direct administration of the State Health Secretariat of the Federal District (SHS-DF).Based on structural issues, the described results have demonstrated that the CSDF has its own headquarters, budget allocation, as well as a Board of Directors implemented with parity, uses permanent committees, performs and par-ticipates in training processes. Such data in the literature refer to the institutional design, which focuses on dynamics and functioning, on the definition of rules and norms, reflecting the de-mocratizing potential of health councils18.
Moreira and Escorel19, when researching more than five thousand Brazilian municipalities, dis-cussed issues related to the structuring of councils based on three factors: (i) autonomy, (i) organiza-tion and (iii) access. Regarding the autonomy (i) variable, the results found pointed to the struc-tural difficulties of the health councils,such as the lack of a ground telephone line, Internet access, human resources, a head office for operation, as well as budgetary autonomy. The most serious situation was observed in municipalities that had up to 50,000 inhabitants, that is, in this case, the population factor was strongly associated with the autonomy19. Regarding the organization (ii) category, the results were negative in relation to the participation in training, internal operation committees, being positive only regarding the frequency of meetings, which is monthly19. This differs from the reality presented by the CSDF, which shows autonomy and organization based on the listed parameters.Access (iii) was the best evaluated dimension among the Brazilian munic-ipalities, signaling the possibility that political tors may assume the presidency of the council ac-cording to the legal scope, supported by the inter-nal regiments of the councils, as well as ensuring thepopulation’sparticipation during the ordinary meetings19. This fact resembles the reality evi-denced in this case study of the Federal District.
The Health Councils, in the 1990s, became institutionalized and expressed the need for an
approximation between Government and soci-ety. They formalized the participation of society and the social control in the construction of the political health agendas, being influenced by the national political situation20. Based on the analy-sis of the minutes and the constitution of themat-ic classes, it was verified that in fact the national situation of the SUS organization in Health Care Networks (RAS), with Primary Health Care (PHC) as the health serviceregulatory body was predominant in the health agenda of the Federal District during the studied period.
The references to Resolution 465, dated of October 4, 2016, of the CSDF, showed that this legislation materializes the guidelines proposed at the 9th Health Conference of the Federal Dis-trict, allowing the implementation of the PHC conversion in the Federal District, determining that the Family Health Strategy (FHS) would be considered the priority strategy of SHS-DF, being responsible for the redistribution of health pro-fessionals already found in the human resources structure of the department, as well as the reor-ganization of the healthcare model of the Federal District public health network.
The resolutions of health councils have al-ready been the subject of studies and problemati-zations, in which their existence as an instrument of social control or bureaucratic document was considered, suggesting the practice of the council away from its role of proposing health policies, but focused on the approval of already estab-lished programs and projects of the health secre-tariat to which it was associated21. In contrast, at least regarding this situation related to the PHC Reform in the SUS / DF, anexperience that was distant from the CSDF was disclosed, in leading the reform of the PHC model embodied in Res-olution 465/2016.
Up to 2017, the coexistence of the traditional model and specialties in the Basic Health Units with the Family Health Strategy (FHS) prevailed in the Federal District PHC, which in fact had a great impact on the overall restructuring of health services at this level of care.The CSDF case study differs from the findings of Van Strallen11, who concluded that councils have little impact on health service restructuring, whereas it agrees with Dúran and Gerschman20 regarding the need for an approximation between Government and society for the construction of political health agendas.
There is no doubt that the Constitution of the Republic and the infraconstitutional legislation create a model of public management that seeks
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to stimulate the population’s participation in reaching the full exercise of citizenship, with so-cial participation beingin close harmony with the process of democratization of the public power, as it advocates the democratic principle.The con-struction of consensus, therefore, is the method that allows and consolidates the conditions for greater social access and participation in the de-cisions of public managers, and the meetingof the different interests of multiple social groups, paving the way for the responsible exercising of citizenship22.
Social participation in the public health man-agement of the Federal District wasdemonstrated in the analysis of the minutes, since their con-tents showedthe discussion of the management models, the creation and structure of permanent committees, the consensuses and debates for de-liberation of varied subjects, among which are the restructuring of Primary Health Care, anal-ysis of Annual Management Reports, Annual Programming and Health Plan, voting, approval, inspection and participation in hiring services.
However, despite having a co-management character, the deliberative democracy within the CSDF is the result of the voting process carried out in its plenary sessions and not the result of debates that reach a consensus, that is, the pro-cess of exchanging ideas, the production of di-vergent proposals and the search for consensus, must precede the votes. This process was not ev-idenced in the minutes. For those whodeliberate, not all topics and subjects should be submitted to deliberation23.
Regarding the CSDF, it is necessary to seek congruences between the Health Conferences’ guidelines and the topics and demands that emerge circumstantially. The advances achieved in the Federal District health policy through so-cial participation are plentiful, including the ac-tions of the Regional Health Councils and also of the most assorted Health Conferences held in the region.We highlight the advances in the consol-idation of SUS as a Government policy that has PHC as a component and a preferential gateway to the service network, capable of meeting 85% of the population’s health needs24 and the search for effective achievementof organizational and doctrinal principles, such as decentralization and regionalization, as well as integrality and univer-sality, respectively.
Final considerations
It is sensible to characterize the Health Council of the Federal District as a permanent and delib-erative instance of social participation in health of the SUS, which aggregates the segmented and equal representations of managers, workers and users. These social actors timely and jointly con-structed a new organization of PHC services in the Federal District, aiming at increasing cover-age, expanding service provision and guarantee-ing the right to health.
The descending hierarchical classification showed that Class 4, called “Instruments and ac-tions aimed at the structuring of Primary Health Care as a regulator of the service network and lev-els of health care”, as the most frequent category (23.4%), among the five existing classes. Thus, we demonstratedthe central role performance that the Federal District Health Council exercised, concerning the origin of the primary health care model reform in the region,by proposing and creating a specific resolution that included guide-lines and had an impact on decision-making by the SHS-DF, namely: Resolution 465/2016 of the Federal District Health Council, which preceded Ordinances 77/2017 and 78/2017,which estab-lished the Primary Health Care Policy in the Fed-eral District.
Collaborations
DSS Vilaça, DS Cavalcante and LM Moura par-ticipated equally in the study design, definition of objectives, data analysis, writing and final re-view of the manuscript.
Acknowledgements
The authors would like to thank the Federal Dis-trict Health Council and the National Health Council for the availability of the minutes and public data provided by the information system that improved this study.
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Article submitted 15/06/2018 Approved 06/02/2018
Final version submitted 01/04/2019
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